Addressing social determinants is key to transforming healthcare system

Case managers play critical role in working with complex-care populations

By Melanie Marshall

The U.S. healthcare system has been the subject of intense debate over the past few years, but there’s one thing most can agree on: much of the challenge involves patients with complex needs that have a devastating impact on their own health and on healthcare costs nationwide.

Those needs – including poverty, hunger, and housing insecurity – are social determinants of health, defined by the Centers for Disease Control as “conditions in the places where people live, learn, work, and play (that) affect a wide range of health risks and outcomes.”

The idea isn’t new or surprising, said Erin Westphal, Program Officer with The SCAN Foundation, a public charity focused on transforming care for older adults: “You can’t expect someone who is a diabetic to eat well, test their blood sugar, and keep their insulin refrigerated, when they’re homeless.”

“You can’t expect someone who is a diabetic to eat well, test their blood sugar, and keep their insulin refrigerated, when they’re homeless.”

What’s different now is a movement in healthcare to look for solutions, she said. That takes multiple resources, including front-line experts who can pull them all together: highly skilled case managers.

‘The pressing need of our time’

The national conversation about social determinants is underscored by research that shows how much they affect human suffering and healthcare spending. A 2011 study by the U.S. Department of Health & Human Services’ Agency for Healthcare Research and Quality found just 5 percent of the U.S. population accounts for 50 percent of total healthcare costs, and 1 percent of the population accounts for 25 percent. People with behavioral health issues, low-incomes, poor education and limited access to health care are more likely to become super-utilizers, according to other studies.

Many of the chronically ill people who show up in hospital emergency rooms have underlying social needs and behavioral health conditions that are unmet and untreated, said Dr. Kelly Pfeifer, Director of California Health Care Foundation’s (CHCF) High-Value Care team. These unmet needs lead to worsening health and costly readmissions.

Breaking that cycle is “the pressing need of our time,” Pfeifer said.

Case managers or care managers – particularly those who understand how to work with complex populations – are a key part of the solution, she said. Last year, CHCF teamed up with The SCAN Foundation to underwrite Care Excellence, an online education program for case managers that includes a focus on people with complex-care needs. Effective care managers identify those needs, and assemble the resources to meet them, Pfeifer said.

“Unmet behavioral and social needs can create catastrophic medical problems. A case manager can partner with a patient to help get the basic things in place – housing, food, drug treatment – focusing on what matters most to the patient,” she said.

Health plans adapting, innovating

That’s the strategy at Inland Empire Health Plan (IEHP), a Medi-Cal managed-care health plan serving roughly 1.2 million members in Southern California’s Riverside and San Bernardino counties. Case managers at IEHP have always worked to connect members with basic needs like food and transportation, but that approach has deepened in recent years as the agency’s membership has skyrocketed, said Jeanna Kendrick, IEHP’s Senior Director of Care Management.

Kendrick said social determinants of health is “kind of the new buzzword, but it’s always been our biggest issue. We know there’s no way you’re going to get engagement from people on addressing their medical problems until you tackle the social issues at the forefront of their lives – food, housing, behavioral health.”

When such needs are addressed, the impact is clear, Kendrick said: “If you can get someone a roof over their head and food in their belly, they’re not going to go to the emergency room 12, 14, 15 times a year.”

IEHP is embarking on a pilot program with the Institute on Aging and Brilliant Corners that will ultimately transition roughly 100 IEHP members in custodial care into community housing, Kendrick said. The move comes amid a staggering increase in homelessness in Southern California, including an 11 percent jump in the past year in Riverside County and a 23 percent increase in Los Angeles County.

A revolution in case management

Innovative programs for complex-care patients can not only change lives, but can potentially transform the healthcare system, Pfeifer and Westphal said. There’s new momentum behind such programs, in part because of public policy changes that hold providers responsible for outcomes of care.

“… the difference now is that case management is no longer only focused on medical needs…”

“Leaders from the aging, disability and community-based sectors have known for decades that the issues that affect people’s daily lives are really the most important, but now we’re seeing the healthcare industry start to address that,” Westphal said. That means the scope of care management is expanding in ways that could yield significant results.

“We’ve had care managers forever, but the difference now is that case management is no longer only focused on medical needs – it takes into account the whole person and requires a difference set of skills and expertise,” she said.

Critical need for complex-care training, data

The Care Excellence Advanced Concepts curriculum helps build those critical skills, Pfeifer said. It provides expert instruction in social determinants of health and working with special populations, as well as building skills in helping patients take charge of their health, using motivational interviewing and collaborative problem solving.

The series was designed with input from Camden Coalition of Healthcare Providers, founded in 2003 by New Jersey physician Jeffrey Brenner, whose groundbreaking primary care practice became a model for addressing medical and social-service needs of people in low-income neighborhoods.

Camden Coalition is working on a randomized trial to test the hypothesis that good care management for people with complex needs improves outcomes while reducing costs, Pfeifer said.

IEHP plans to examine the impact of its housing program in the coming years, Kendrick said, but she’s confident the results will be positive.

“It’s really just common sense,” she said. “If you just put some basic services around those with complex needs, it improves their quality of life and improves satisfaction – not just for the patient, but for the provider.”